HITECH Act Assures Meaningful Use Care Coordination For Some
Brandon Danz, M.P.A.
The passage of the ARRA HITECH Act in 2009 fostered significant advancements in patient engagement and care coordination by incentivizing primarily physical health providers and acute care hospitals to make smarter use of technology. Specifically, the Act provided funding for eligible providers and hospitals to adopt electronic health records (EHR) and then “meaningfully use” those EHRs to improve care coordination, reduce health disparities, promote population health, enhance patient engagement, and maintain patient privacy.
Eligible providers and hospitals benefit greatly from transferring patient records from the filing cabinet to the computer. Information becomes instantaneously available to inform improved patient engagement and person-centered care decisions. Most importantly, this information can be used to manage a patient’s care across the many health systems he or she uses.
However, therein lies the rub: Cross-systems, patient-centered care is only possible when all providers are operating on a level playing field. Notably absent from HITECH are EHR and meaningful use incentives for behavioral health, long term care, and other post-acute and safety net health care providers. The decision to exclude these providers was somewhat paradoxical considering the Act’s aims of improved coordination and a greater focus on population health.
A report issued by HHS in 2013 shows that excluded from the Act are almost 16,000 nursing homes in the United States serving 1.3 million individuals at the cost of $143 billion annually. Also excluded are over 12,000 home health agencies which serve an additional 3.4 million individuals at an annual cost of $44 billion, and over 5,000 hospice organizations treating 1.5 million patients at a cost of $17 billion. As our nation ages, these numbers will grow dramatically. Improved coordination between acute care hospitals and long term care providers will be integral to decreasing avoidable admissions and readmissions, managing chronic disease, decreasing infection rates and complications, and facilitating stronger, more patient-centered end-of-life care.
Within the behavioral health field, almost 2,500 psychiatric hospitals were left out of the Act, which serve 2 million Americans at a price of $23 billion annually, along with 4,500 residential treatment facilities serving over 314,000 individuals with a cost of over $21 billion. Some of America’s most complex and costly medical cases have significant co-occurrence of behavioral health and physical health issues. This population has benefited little from a siloed approach to medical care. Failing to include behavioral health providers in EHR incentives has served in many ways to broaden the chasm between physical health and these very important systems of care.
Together, these five provider groups alone account for a total spend of almost $250 billion annually to treat 8.5 million Americans. And these are just a sampling of the providers who were left out of the HITECH Act. Inpatient rehabilitation facilities, community mental health centers, clinical psychologists, clinical social workers, FQHCs, rural health centers, ambulatory surgical centers, renal dialysis facilities, pharmacies, facilities for individuals with intellectual disabilities – and many more providers across the systems of care were given no incentive to adopt and meaningfully use EHRs for the millions of Americans whose “person centered” care depends on increased coordination with these services.
Market Forces at Work: Fortunately, where government incentives have failed these providers, competitive market forces are advancing innovation. Competition has pushed many providers who are not covered by HITECH incentives to adopt EHR platforms on their own dime. Providers of behavioral health and long term care services have recognized the power of EHR systems to improve care management, patient engagement, and coordination of services. A 2012 nationwide survey of PACE organizations (which provide long term, comprehensive managed care for the frail elderly) found that 69% of these organizations use EHRs and of those that do not, 63% reported plans to adopt EHR systems within the next 12 months. Further, a 2013 national report on home health and hospice providers shows that 78.1% use an electronic health record system. Similar industry reports show an equally surprising number of other long term care and behavioral health providers currently using EHRs.
Barriers to Entry: This is not to say, however, that adoption of EHRs within these industries has been as uniform as that taking place in the physical health world. The barriers to entry into health care’s electronic age can be prohibitive. Unlike acute care hospitals, many of these providers have traditionally operated in a low tech environment. The potential utility gained from the voluntary adoption and meaningful use of EHRs can seem quite distant and minimal to a small practice whose paper filing system has been in place for decades. Second, existing fee-for-service payment methodologies for behavioral health and long term care do not incentivize providers to use technology to drive down costs and increase coordination. Third, because these providers are not covered by the provisions and oversight of the HITECH Act which require EHR records to be certified and interoperable, they have hundreds of systems to select from, which vary significantly in quality. It can be difficult to differentiate between a high quality platform and an IT company that is out to make a quick buck selling a subpar system. The risks are huge. Adopting an EHR system means:
- making a significant capital investment with a largely unpredictable ROI;
- investing in training staff on how to use that system (which isn’t reimbursable time);
- transitioning thousands of paper documents into electronic records;
- and then, once all of this is done, learning how to leverage this new system to bring value to care delivery in a way that does not reduce revenue.
- Lastly, if that system proves to lack interoperability with other systems, then the whole investment is a wash.
Without HITECH incentives, cross-systems sharing of health records to drive stronger patient-centered care is taking place only as fast as the competitive market allows. With perverse payment methodologies that reimburse volume over coordination and other regulatory barriers preventing the sharing of some data, the health care community must continue to pursue the noble goals of the HITECH Act with one hand tied behind its back. Government regulators at both the federal and state levels should work to address this through targeted incentive programs aimed at improving the use and interoperability of EHR systems throughout all health care systems.